HYGIENE, CLIENT SAFETY
PRINCIPLES OF PATIENT HYGIENE AND
SAFETY
Providing
for a patient's hygiene is probably the most basic of all nursing care
activities, but it is undoubtedly one of the most important. Not only is it a
provision for the patient's physical needs; it also contributes immeasurably to
the patient's feeling of emotional well-being.
PURPOSE OF THE PATIENT'S DAILY
a.
Removal of bacteria from the skin.
b.
Confinement in bed increases
perspiration, and bacterial growth is stimulated by moisture.
c.
Skin irritation from hospital bed
linens may result in skin breakdown and subsequent infection.
d.
Relaxation effect on the patient.
e.
Stimulation of blood circulation to
the skin, respirations, and elimination.
f.
Maintenance of joint
mobility.
g.
Improvement of the patient's
self-image and emotional and mental well-being.
h.
Providing the nurse with an
opportunity for health teaching and assessment.
i.
Providing the nurse with an
opportunity to give the patient psychological support.
o
The process of building rapport may
begin during the initial bath.
o
The bath aids in the development of
the therapeutic nurse-patient relationship as the patient has the nurse's
undivided attention.
PHYSICAL
CONDITIONS WHICH ENCOURAGE SKIN BREAKDOWN IN A PATIENT WHO IS CONFINED TO BED
a.
Immobility. Continuous
pressure over any body part impairs circulation to that part and can cause
breakdown and eventual ulcerations.
b.
Incontinence.
If the patient is unable to control the bladder or bowel functions, skin
breakdown is likely to occur due to the presence of moisture and bacteria on
the skin.
c.
Emaciation.
An emaciated patient may be prone to skin breakdown over bony prominence
(heels, elbows, and coccyx).
d.
Obesity. An obese
patient may have many skin folds where perspiration and bacteria may contribute
to skin breakdown.
e.
Age-Related Skin Changes.
An older person's skin is very thin and inelastic. The sweat and oil glands are
less active. Thin, dry skin is more susceptible to pressure areas and skin
breakdown.
f.
Any Disease or Condition that Affects
Circulation. Any
disease or condition that affects circulation can encourage skin breakdown in a
patient who is confined to bed.
NURSING INTERVENTION TO PREVENT SKIN BREAKDOWN
a.
The time of the patient's bath or
back massage is the most logical time to thoroughly observe the patient's skin
for pressure areas.
b.
At the first sign of redness, the
area should be washed with soap and water and rubbed with lotion; measures
should then be taken to keep the patient off the reddened area.
c.
Report any signs of pressure to the
charge nurse.
d.
Keep sheets under the patient clean,
smooth, and tight to help eliminate skin irritation.
e.
Ensure adequate nutrition and fluid
intake, according to physician's orders.
f.
Every effort should be made to keep
urine and feces off the patient's skin, washing the
skin with soap and water and keeping the buttocks and genital area dry (lotion
or powder may be used depending upon the patient's skin type) when the patient
is incontinent.
g.
Obese patients may need assistance
washing and drying areas under skin folds (groin, buttocks, under breasts, and
so forth.)
h.
For the patient with very dry skin,
various bath oils may be added to the bath water.
o
Soap may be omitted because of its
drying effect.
o
Lotions and oils may be used after
the bath.
TIMING OF
PATIENT HYGIENE PROCEDURES
A patient's
bath may be given at any time, according to the patient's needs, but certain
routines are generally followed on a ward.
Morning Care.
1.
The procedure followed in the morning
affects the patient's comfort throughout the day.
2.
Each morning before breakfast, the
patient should be assisted to the bathroom, or a bedpan or urinal should be
provided, according to the patient's activity level.
3.
The patient is then given the
opportunity to wash his/her hands and face and brush his/her teeth. The bed
linen is straightened, and the overbed table is
cleaned in preparation for the breakfast tray.
4.
After breakfast, the patient has a
complete bath (type is dependent upon the patient's condition and mobility),
mouth care, a change of clothing, and a back massage.
5.
Bed linens are changed; and the unit
is cleaned and straightened to provide a comfortable and safe environment for
the patient.
Evening Care.
1.
The care the patient receives at the
end of the day greatly influences the patient's level of relaxation and ability
to sleep.
2.
An opportunity is provided for
elimination; the patient's hands and face are washed; the teeth are brushed; a
back rub is given.
3.
Bed linens are straightened; the
patient's unit is straightened to ensure comfort and safety. It is important
that there are no items, which the patient could slip on, or fall over, such as
chairs or linens, on the floor.
PROVIDING FOR
SELECTED PATIENT NEEDS WHILE BATHING A PATIENT
Safety.
1.
The bed may be in the high position
during the patient's bed bath, but should be placed in the low position upon
completion.
2.
The side rails should be up after the
patient's bath for the patient who is confined to the bed.
o
Side rails help to prevent falls for
the elderly patient or the patient who is confused or has a decreased level of
consciousness.
o
The legal aspect requires diligence
on the part of nursing personnel.
3.
The patient's call light should be
within easy reach to prevent the need to reach for it and risk falling out of
bed and to provide easy access in case of pain or distress.
4.
Fire safety in the patient care area
calls for the following rules:
o
No smoking in bed.
o
No smoking if oxygen is in use.
5.
Always wash your hands before
entering and upon leaving the patient's room.
Privacy.
1.
Respect for the patient's privacy
decreases the patient's emotional discomfort during personal care.
2.
Keep the door to the patient's room
closed.
3.
Pull the curtains around the unit and
drape the patient's body during care.
4.
Allow the patient to complete as much
personal care as possible; self-care is appropriate and provides additional
privacy.
Comfort.
1.
Ensure a comfortable temperature in
the patient's room.
2.
Close any windows and the door to the
patient's room to prevent drafts and chilling.
3.
Drape the patient appropriately
during the bath.
4.
For a bedside bath, maintain bath
water between 110oF and 115oF; change the water as it cools and/or gets soapy.
SIGNIFICANT
NURSING OBSERVATIONS DURING THE BATHING PROCEDURE
Physical
Observations.
1.
Observe the skin under good, natural
light.
2.
Any abnormal skin condition should be
described as to its location, color, and size and how
it feels to the patient.
3.
The following skin observations
should be checked upon admission and daily thereafter:
o
Cleanliness.
o
Odor.
May be caused by sweat secreted by the sweat glands; by abnormal conditions,
such as infection or kidney disease; or by bodily discharges (urine, feces) that need to be cleaned.
o
Texture. Smooth and elastic or dry
and rough; nutritional deficiencies can influence skin texture.
o
Color.
Reddened areas that could indicate pressure, cyanosis (bluish tinge) or
jaundice (yellowish tinge).
o
Temperature. Hot skin could mean
fever; cold skin could mean poor circulation.
o
Sensitivity. Pain, tenderness,
itching, or burning.
o
Swelling (edema).
Stretched or tight appearing; usually begins in the ankles or legs or any other
dependent part; may be associated with injury.
o
Skin lesions. Rashes, growths, or
breaks in the skin.
4.
Observations may begin at the head
(scalp) and proceed to the feet in a systematic manner.
Psychosocial Observations.
1.
Problems in this area may be related
to the patient's present problems.
2.
The time of the patient's bath may be
a good time to find out more about the patient's psychosocial needs.
3.
Remember that the patient's nonverbal
communication may tell you much about the way he/she is feeling.
Oral
Care Supplies
BASIC PRINCIPLES OF MOUTH CARE
Purposes.
1.
Provide oral care of the teeth, gums,
and mouth.
2.
Remove offensive odors
and food debris.
3.
Promote patient comfort and a feeling
of well-being.
4.
Preserve the integrity and hydration
of the oral mucosa and lips.
5.
Alleviate pain and discomfort,
thereby enhancing oral intake.
General Guidelines.
1.
Oral hygiene should be performed
before breakfast, after each meal, and at bedtime.
2.
Oral hygiene is especially important
for patients receiving oxygen therapy, patients who have nasogastric
tubes, and patients who are NPO. Their oral mucosa dries out much faster than
normal due to their mouth-breathing.
3.
You should provide for patient
privacy during the procedure, as this is an extremely personal procedure for
most patients.
4.
Oral care for the unconscious patient
should be performed at least every four hours.
5.
Lipstick, chap
stick, or vaseline may be applied to the lips
to keep them from drying out.
Nursing
Records. Nursing observations for the
patient's mouth should be recorded in the clinical record, noting such factors
as:
1.
Bleeding.
2.
Swelling of gums.
3.
Unusual mouth odor.
4.
Effect of brushing the teeth. Note if
there is bleeding when you brush the patient's gums and teeth.
Conscious Patients with Dentures.
1.
General considerations.
o
Many patients are sensitive or
embarrassed about wearing dentures; therefore, the patient's privacy should be
respected when the dentures are cleaned.
o
Dentures must be handled carefully;
they are fragile and expensive, and the patient is handicapped without them.
o
If the dentures are left out of the
mouth for any period of time, place them in a covered opaque container with the
patient's name on the container.
o
Dentures must be kept in water to
preserve their fit and general quality; the color may
change if they become dry.
o
You may avoid breaking the dentures
while cleaning them by holding them over a basin of water with a washcloth
folded in the bottom.
2.
Dentures are brushed in the same way
as natural teeth; be sure to rinse them well.
3.
The denture cup should be labeled with the patient's name and room number.
4.
Never use hot water to rinse the
dentures as it could warp them; use cool or lukewarm water.
5.
The patient's gums and soft tissues
should be cared for at least twice per day while the dentures are out of the
mouth; a soft-bristled toothbrush, swab, or gauze-covered tongue blade dipped
in mouthwash should be used to cleanse the gums, tongue, and soft tissues.
Patients
With Mouth Complications. The following
problems are common in patients receiving chemotherapy and radiation therapy:
1.
Bleeding.
o
Observe the patient's mouth
frequently for the amount of bleeding present and the specific areas.
o
Do not floss the patient's teeth; use
a Water-pik®.
o
Brush the teeth and clean the mouth
using one of the following methods:
§
1 Brush the teeth carefully with a
very soft toothbrush.
§
2 Wrap a tongue blade with a gauze
sponge saturated with a prescribed solution; carefully swab the teeth and
mouth. Do not use lemon/glycerine swabs or commercial mouthwash because they
contain alcohol, which causes burning.
2.
Infection.
o
Observe the patient's mouth for
appearance, integrity, and general condition.
o
Wear clean gloves during the
procedure.
o
Obtain a culture, if ordered.
o
Do not floss the teeth if the mouth
is irritated or painful.
o
Assist the patient with brushing the
teeth and cleaning the mouth, using a soft toothbrush or a gauze-padded tongue
blade.
o
Rinse the mouth with water and the
prescribed solution, if ordered.
3.
Ulcerations, to include
stomatitis.
o
Basic procedure for the patient with
an infection should be followed.
o
If the patient's mouth is extremely
painful, rinsing the mouth with a local anesthetic,
as prescribed by a physician, may be necessary.
o
Mouthwash and other solutions which
contain alcohol should not be used for the patient with ulcerations as they are
frequently very painful.
Unconscious Patients.
1.
Oral care should be performed at
least every four hours.
2.
Oral suctioning may be required for
the unconscious patient to prevent aspiration.
3.
A soft toothbrush or gauze-padded
tongue blade may be used to clean the teeth and mouth.
4.
The patient should be positioned in
the lateral position with the head turned toward the side to provide for
drainage and to prevent aspiration.
GUIDELINES
FOR SHAVING A MALE PATIENT
If
the patient is alert, question him about his shaving habits, and follow his
routine as closely as possible.
1.
Gather equipment and supplies.
o
Towels.
o
Washcloth.
o
Basin with hot water.
o
Shaving cream.
o
Razor.
o
Soap.
o
Aftershave lotion.
2.
Wet the wash cloth, wring
out any excess moisture, and apply it to the beard area (to soften the beard).
3.
Apply shaving cream to
the beard.
4.
Shave the beard on the
cheeks and upper lip in the direction that the hair grows.
5.
Shave the beard on the
neck against the direction of the hair growth.
6.
Wash off any remaining
shaving cream.
7.
With clean water, finish
washing the patient's face.
o
Always use an electric
razor on patients with bleeding disorders to prevent uncontrollable bleeding
from facial cuts.
o
Do not use plugged in
electric razors on patients who are receiving oxygen therapy because of the
danger of combustion; safety razors or rechargeable battery operated shavers
are safe.
o
Consult with the charge
nurse before shaving any patient who has had facial surgery or who may have hemophilia.
o
Patients who are
combative, suicidal, or disoriented should have supervision and assistance
while shaving.
Perineal
care is often referred to as "pericare;" it
consists of external irrigation of the vulva and perineum following voiding or
defecation and is part of the routine A. M. and P. M. care. Patients may be
able to perform their own perineal care or may need
partial or total assistance from the nurse. Embarrassment on the part of the
patient and the nurse can be effectively dealt with by ensuring patient privacy
during the procedure and not totally exposing the patient's genital area.
Key points:
1.
Ensure patient privacy.
2.
Wipe from front to back
(vagina toward rectum) on female patients to avoid contaminating the vagina or
urethral meatus.
3.
Do not use the same
washcloth for any other portion of the patient's bath.
Principles for Shampooing the Bed Patient's Hair.
1.
The supine position is
preferred for weaker patients.
2.
Patients with significant
heart or lung disease will not tolerate being supine; they must be in a sitting
position.
3.
Hair care should be given
regularly during illness, just as it would be normally.
Purposes of
Hair Care.
1.
Hair care improves the
morale of the patient.
2.
It stimulates the
circulation of the scalp.
3.
Shampooing removes
bacteria, microorganisms, oils, and dirt that cling
to the hair.
Nothing points out loss of independence quite
as much as an inability to perform personal hygiene unassisted. Your
thoughtfulness and the professionalism you exhibit when assisting a patient
with hygiene needs will foster that patient's feelings of independence,
confidence, trust, and comfort.
SAFE
ENVIRONMENT
Safety has a positive association with health promotion and illness
prevention. A safe environment reduces the risk of accidents, subsequent
alterations in health and lifestyle, and the cost of health care services.
There are many factors in the environment that can threaten safety
FACTORS
AFFECTING SAFETY
Client safety is influenced by several factors
such as age, lifestyle, sensory and perceptual alterations, mobility, and
emotional state.
Age
Risk for injury varies with chronological age and developmental stage.
Health education about preventive measures can facilitate injury prevention for
various age groups
As infants mature, their potential for injury increases. Infants, toddlers, and preschoolers
are explorers of their environment. Most accidents involving these age groups
are preventable with careful adult supervision to prevent falls from bed,
burns, electrical hazards, choking on small objects, and
drowning.
As school-age children explore their environment outside the home, their
risk for injury increases. Prevention measures during this stage focus on not
accepting candy, food, gifts, or rides from strangers; bicycle, skating, and
swimming safety; and substance abuse.
Adolescents and young adults usually enjoy good physical health;
however, their lifestyles put them at risk for injury. Since this age group
spends much time away from home, collaborative educational efforts among
parents, schools, and community health care providers need to focus on
environmental safety. High-risk factors for injury and death are automobile
accidents, substance abuse, violence, unwanted pregnancies, and sexually
transmitted diseases.
Studies indicate that adolescents who initiate substance use in middle
school and continue into high school are likely to become multisubstance users (tobacco, alcohol, and drugs).
The progression from lighter to heavier use of illicit substances during
adolescence leads to more serious multisubstance use
careers.
Adult risk for injury is generally related to lifestyle, work practices,
and behaviors. Prevention measures during this period emphasize nutrition,
exercise, and occupational safety. High-risk factors for this age group
include fatigue, anxiety,
sleep pattern disturbances, caregiver role strain, and altered health
maintenance.
The older adult is prone to falls, especially in the bathroom, bedroom,
and kitchen, because of a loss of agility and visual acuity, predisposition to
dizziness and syncope, and side effects of medications. Prevention measures for
this age group emphasize slow position changes, good lighting, hand rails, and skidproof strips in the bathtub or shower and
under rugs and carpets.
Each year, approximately one-third of people over the age of 65 who live
at home fall; 15% of falls cause serious injuries, half of which are fractures
that cost about $10 billion for hospital care (Winslow, 1998). Two Maryland hospitals
worked together to implement a fall precaution program in their
medical-surgical units and within 1 year lowered their fall rates from 9.3
falls per 1,000 client days to 7.3 per 1,000 client days (Sullivan & Badros,
1999).
Lifestyle
Lifestyle practices can increase a person’s risk for injury and
potential for disease. Individuals who operate machinery; experience stress,
anxiety, and fatigue; use alcohol and drugs (prescription and nonprescription);
and live in high-crime neighborhoods are at risk for injury. Risk-taking
behaviors such as daredevil activities, driving vehicles at high speeds, and
smoking are factors associated with accidents.
Sensory
and Perceptual Alterations
Sensory functions are essential for accurate perception of environmental
safety. If one of the senses is altered, then the other senses compensate to
facilitate perception of the environment. For instance, a blind person usually
will develop a keen sense of touch and hearing. Clients who have visual,
hearing, taste, smell, communication, or touch perception impairments are at
increased risk for injury. These clients are often not able to perceive a
potential danger.
Mobility
Clients who have impaired mobility are at increased risk for injury,
especially falls. Mobility impairments may be a result of poor balance or
coordination, muscle weakness, or paralysis. Immobility may also precipitate
physiological and emotional complications such as decubitus and depression, respectively.
Emotional
State
Emotional states such as depression and anger affect a client’s
perception of environmental hazards and degree of risk-taking behavior. These
emotional states alter a client’s thinking patterns and reaction time. Usual
safety precautions may be forgotten during periods of emotional stress.
Self-confidence decreases when an elderly person falls; they tend to limit
their activities because they fear falling again (Winslow, 1998).
Types
of Accidents
In the health care setting, accidents are categorized by their causative
agent: client behaviors, therapeutic procedures, or equipment:
1. Client behavior accidents occur when the client’s behavior
or actions precipitate the incident; for example,
poisonings, burns, and self-inflicted cuts and
bruises.
2. Therapeutic procedure accidents occur during the delivery
of medical or nursing interventions; for example,
medication errors, client falls during transfers,contamination of sterile instruments or wounds, and improper performance of nursing
activities.
3. Equipment accidents result from the malfunction or improper
use of medical equipment; for example, electrocution
and fire.
National and institutional policies establish safety standards; for
example, the risk for equipment accidents can be reduced by having the
biomedical engineering department check the equipment inspection label prior to
use. All accidents and incident reports must be fully documented according to
institutional protocol.
Potential Occupational Hazards
Nurses and other health care providers are at risk for injury in the
workplace. Every day in the Unites States, 9,000 health care workers sustain a
disabling injury on the job, according to the National Institute for
Occupational Safety and Health (NIOSH) (Slattery, 1998). The Occupational
Safety and Health Administration (OSHA), a division of the Department of Labor,
has the power to enforce safety standards, and to cite and discipline agencies
that are not in compliance with the standards (Bending, 2000).
Numerous hazards exist in today’s workplace such as latex allergy,
blood-borne pathogens, work-related musculoskeletal disorders (MSDs), chemotherapeutic agents, environmental pollution,
and violence. Findings from studies indicate that nurses who prepare or
administer chemotherapeutic agents are exposed to occupational hazards from
dermal absorption, ingestion, and inhalation from aerosolization of powder or liquid during
reconstitution or from spillage (DelGaudio &Menonna-Quinn,
1998). According to the Bureau of Labor, almost two-thirds (64%) of nonfatal
workplace assaults occur in nursing homes and hospitals (Slattery, 1998). The
salient points regarding latex allergy and MSDs are discussed here; blood-borne pathogens are discussed
later in this chapter.
Latex
Allergy
NIOSH (1997) issued an Alert entitled Preventing Allergic Reactions to
Natural Rubber Latex in the Workplace. Latex products are manufactured from
a milky fluid derived from the Brazilian rubber tree, Hevea brasiliensis. The allergic response is
attributed to the proteins contained in the milky fluid and to the chemicals
that are added during the processing and manufacture of commercial latex. There
are three types of latex reactions: irritant contact dermatitis; allergic
contact dermatitis, the most common type of reaction; and immediate
hypersensitivity, a systemic reaction also called type 1 IgE–mediated
reaction.
Since 1992, when OSHA issued regulations requiring health care workers
to wear gloves and other protective devices such as surgical masks and goggles
as a safeguard against blood-borne pathogens, health care workers were placed
at risk for developing latex allergy. Commercial latex is in more than 20,000
medical products (Burt, 1999) such as blood pressure cuffs, stethoscopes,
catheters, and wound drains, to name a few, as well as many household items. Reports
indicate that 1–6% of the general population and about 8–12% of regularly
exposed health care workers are sensitized to latex (NIOSH, 1997).
NIOSH
(1997) recommends that employers and employees take a common sense approach
based on current knowledge to protect workers from latex exposure and allergy
in the workplace; refer to the accompanying display for NIOSH’s recommendations. NIOSH recommends
that, if latex gloves are worn, they should be powder free and low allergen because these
gloves are less likely than powdered ones to produce allergic responses (Gritter, 1998).
Work-Related Musculoskeletal Disorders
One-third of all occupational injuries reported by employers every year
to the Bureau of Labor Statistics are work-related MSDs.
Employers reported a total of 626,000 lost workdays in 1997, with these
disorders costing workers’ compensation more than $15-$20 billion (OSHA, 2000).
According to OSHA (2000), it is estimated that only 28% of all
workplaces in general industry have voluntarily implemented ergonomics
programs. In response to these workplace hazards, OSHA has issued mandatory
standards that require all employers to set up ergonomic programs to prevent
work-related MSDs such as back injuries.
Work-related back pain affects 38% of nurses. The predominant cause of
nurse back pain is lifting clients (Slattery, 1998). OSHA ergonomic standards
state that a 51-pound stable object with handles is the heaviest amount that
can be safely lifted. Health care providers are being challenged, in the midst
of personnel cutbacks, to develop and implement safety policies that protect
the provider and support OSHA’s ergonomic
regulations.
The ergonomic standards require that all employers must provide workers
the following information: common MSD hazards; signs and symptoms of MSDs, and
the importance of reporting them early; how to report MSD signs and symptoms;
and a summary of the requirement of the OSHA standard. The standards require
the employer to ensure pay and benefits in the event that an employee needs to
take time off or go on lighter duty because of a work-related MSD.
HYGIENE
Hygiene is the science of health. Hygienic care promotes cleanliness, provides
for comfort and relaxation, improves self-image, and promotes healthy skin.
Client hygiene is an extension of providing client safety and protecting the
client’s defense mechanisms. The health of the body’s first line of defense
(skin and mucous membranes) is promoted by client hygiene. Nurses are
responsible for assuring that the client’s hygienic needs are met. The type of
hygienic care provided depends on the client’s ability, needs, and practices.
Factors Influencing Hygienic Practice
Hygienic needs and practices are unique to each client; nurses should
provide individualized care based on these needs and practices. Hygienic
practices are influenced by several factors: body image, social and cultural
practices, personal preferences, socioeconomic status, and knowledge.
Body Image
Body image is the client’s subjective belief about his or her own physical
appearance. Body image is associated with the client’s emotions, mood,
attitude, and values. A client’s body image directly affects the type of
personal hygiene practiced; this may change if the client’s body image is
altered because of illness or surgical procedures. During this time, the nurse
should help the client maintain hygienic practices in accordance with the
client’s pre-illness level of hygiene and personal preferences.
Social
and Cultural Practices
Social and cultural practices also directly influence hygienic
practices. Clients are socialized to their hygienic practices by family
practices in early childhood. As a person ages, hygienic practices are
influenced by maturational development and socialization with people outside of
the family. For example, teenagers are usually concerned with peer acceptance
and follow the latest trends in personal hygiene. In later adulthood, hygienic
practices may be influenced by coworkers and social networks.
Cultural practices and beliefs are derived from family, religious, and
personal values developed during maturation. Clients from diverse cultural
backgrounds will have differing hygienic practices. For example, some cultures
do not permit women to submerge their bodies in water during the time of menstruation
because there is fear that the woman may drown. In
Personal Preferences
Personal preferences influence when bathing occurs, what products are
used, and what type of bath is performed.
For example, some male clients may shave before bathing, while others
prefer to wait until after the bath. Some clients prefer to bathe in the
morning to facilitate waking, while others prefer to bathe before bedtime to
encourage relaxation and sleep. Unless a client’s health is affected, the nurse
should permit clients to practice their usual routine and use the hygienic
products that they prefer. Individualized nursing care should incorporate the
client’s personal hygiene preferences.
Socioeconomic Status
A client’s hygienic practices may be influenced by socioeconomic status.
Limited economic resources may affect the type, frequency, and extent of
hygiene practiced. Assessment of socioeconomic status provides information
about the availability of hygiene supplies. Some clients may not be able to
afford deodorants, perfumes, soaps, shampoo, and toothpaste. The nurse can
function as an advocate for the client by making referrals to community
agencies that provide assistance to needy persons, for
example, Catholic Charities or a local chapter of the American Association of
Retired Persons (AARP).
Knowledge
Knowledge level influences the client’s understanding about the
relationship between hygiene and health. Thus, knowledge should influence a
client’s hygienic practices. In addition to being knowledgeable, before clients
perform basic hygiene, they must be motivated and believe that they are capable
of self-care.
Frequently, an illness or surgical procedure results in deficient
knowledge about basic hygienic practices. In these situations, the client may
not know the correct procedures or types of hygiene that can be performed. The
nurse is responsible for providing the necessary education about hygiene during
an illness. Sometimes, the nurse may have to perform all hygienic practices for
a client during an illness until the client is able to regain this
ability.
ASSESSMENT
The nursing process facilitates an understanding of the scope of
challenges inherent in the nursing care of clients at risk for injury,
infections, or a self-care deficit.
The assessment data should direct the prioritization of the client’s
problem and accompanying nursing diagnoses.
Clients at risk for injury or infection require frequent reassessment of
their status with appropriate changes in the plan of care and expected
outcomes.
The assessment and physical examination data are correlated with the
laboratory indicators to identify those clients who are at risk for problems
relating to safety, infection, or hygiene. One of the assessment models should
be used to provide structure to the assessment.
Appropriate risk appraisals may be incorporated into the nursing health
history interview.
These core elements of assessment are discussed in relation to clients
in ambulatory, institutional, and home settings. Refer to the accompanying
display for a sample format for developing minimum safety standards applicable
to all health care settings.
Health
History
The nursing health history interview is the first part of assessment; it
provides the client’s subjective specific health data. Key elements of relevant
data regarding the client at risk for safety and infection are obtained in the
health history. See Chapter 6 for a sample of a nursing health history tool.
The client is often asked to complete a health history questionnaire;
however, depending on the client’s status, the nurse may have to perform an
interview to obtain these data. If the client is unable to provide the
subjective data, the nurse must designate on the questionnaire or in the
nursing progress notes who provided
the information.
During the nursing health history interview, assess the client’s general
health perception and management status to determine how the client manages
self-care.
This information will provide data regarding the client’s routine
self-care and health promotion needs. Sample questions that relate specifically
to habits that foster safe, healthy patterns of behavior are presented in the accompanying
display. These questions are appropriate for home health and ambulatory care
settings as well as inpatient settings.
Physical
Examination
A complete health assessment includes a systematic physical examination,
generally conducted from head to toes, in order to obtain objective data
relative to the client’s health status and presenting problems.
When assessing the client to determine the level of risk for injury or
infection and hygienic deficits, focus the physical examination on the following
areas and signs:
• Level of consciousness: Use the Glasgow Coma Scale to evaluate this
attribute.
• Range of motion or total immobilization of an extremity.
• Localized infection: Redness, swelling, warmth, tenderness, pain, and
loss of movement in a specific body part.
• Systemic infection: Fever, with a corresponding increase in pulse and
respirations; weakness; anorexia, with possible accompanying findings of
nausea, vomiting, and diarrhea; enlarged and/or tender lymph nodes.
• Secretions or exudate of
the skin or mucous membranes and detection of crackles, rhonchi, or
wheezes in the lungs on auscultation.
The condition of the skin is a good indicator of a client’s general health status. Assessment of skin integrity provides data concerning a client’s nutritional and hydration status, continuity of intact skin, hygienic practices, and overall physical abilities. Similarly, a client with limited mobility is at risk for developing joint contractures, skin breakdown, and muscle atrophy.
Risk
Factors
A comprehensive nursing assessment involves using specifically developed
risk assessment tools and appraising the client’s environment to detect
potential hazards. The client’s self-care abilities, used for determining the
level of assistance needed in providing hygienic care, are appraised during the
health history. The analysis of relevant risk factors alerts the nurse to
actual or possible risks. Skin integrity is usually compromised when a person
is placed on bed rest. A skin integrity risk appraisal such as the one shown in
the accompanying display should be completed to assist with planning care.
Client
in an Inpatient Setting
Inpatient clients should be assessed for fall and infection risk factors. The hospitalized or institutionalized client’s risk for falls is identified after compiling specific assessment data that are correlated with contributing factors. Each of these indicators carries a specific weight, as shown in the accompanying Fall Risk Appraisal, to determine the client’s risk. The inpatient client should be assessed for falls every shift or as designated by institutional policy. To minimize the chance of falls, make sure the client’s environment is safe: the bed is kept in a low position, side rails are up, personal belongings are in easy reach, and assistive devices (e.g., walker) are nearby.
Client
in the Home
An injury risk appraisal will provide the nurse with assessment data to
determine the client’s level of safety knowledge as previously discussed in the
standard of care for safety. Injuries in the home are primarily the result of
falls, fires, electrical malfunctions, suffocation, weapons, and household and
medication poisonings. Home health nurses may use a safety risk appraisal;
refer to the accompanying display.
The safety risk data assessed in the home environment direct the nurse
in planning for the client and caregiver’s education. The home health nurse
needs to prioritize these data when planning the client’s care. Assessment,
teaching, and outcome evaluation of all safety hazards can take several home
visits.
Diagnostic
and Laboratory Data
Appraising the client’s risk for injury should also include an
evaluation of laboratory findings relative to an abnormal blood profile (e.g.,
altered clotting factors, anemic conditions, or leukocytosis).
Malnourished clients are at risk for injury.
The laboratory indicators for an infection are:
1. An elevated leukocyte (white blood cell [WBC]) and WBC differential:
• Neutrophils: Increased in acute,
severe inflammation
• Lymphocytes:
Increased in chronic bacterial and viral infections
• Monocytes: Increased in some
protozoan and rickettsial infections and tuberculosis
• Eosinophils and basophils: Unaltered in an infectious process
2. An elevated erythrocyte sedimentation rate (ESR): Increased in the presence of
inflammation
3. An elevated pH of involved body fluids (gastric, urine, or vaginal secretions):
Indicates the presence of
microorganisms
4. Positive cultures of involved body fluids (blood, sputum, urine, or other drainage): Indicates
the growth of microorganisms
NURSING
DIAGNOSIS
After data collection and analysis, the nurse is able to formulate a
nursing diagnosis. If Gordon’s Functional Health Patterns model is used to
conduct the assessment, the nurse can use the classification of nursing diagnoses
by functional health patterns that relate to safety, infection, and hygienic
deficits; for example:
I. Health perception–health management pattern
• Risk
for injury
• Risk
for infection
II. Activity-exercise pattern
• Bathing/hygiene
self-care deficit
• Dressing/grooming
self-care deficit
• Toileting
self-care deficit
Risk for Injury
The primary nursing diagnosis Risk
for Injury exists when the
client is at risk of injury as a result of environmental conditions interacting
with the individual’s adaptive and defensive resources (NANDA, 2001). Although
this diagnostic label does not have defining characteristics as set forth by
NANDA, it is categorized as having either internal or external potential
hazards. An internal biochemical risk factor for a client with impaired vision
would be stated as Risk for
Injury related to sensory
dysfunction. In contrast, a home health nurse’s assessment data that identify
drugs on a nightstand with a toddler in the home as creating an external
chemical risk factor for the toddler would be stated as Risk for Injury related to drugs (pharmaceutical
agents).
NANDA (2001) has six defined subcategories of specific risk factors for
this diagnostic labeling:
1. Risk for Suffocation: An accentuated risk of accidental suffocation
2. Risk for Poisoning: An accentuated risk of accidental exposure
to, or ingestion of, drugs or dangerous products
in doses sufficient to cause poisoning
3. Risk for Trauma: An accentuated risk of accidental tissue injury (e.g., wound, burn, fracture)
4. Risk for Aspiration: Risk for entry of gastrointestinal secretions, oropharyngeal secretions, or solids or fluids into the tracheobronchial passages
5. Risk for Disuse Syndrome: Risk for deterioration of body
or body systems as the result of prescribed or unavoidable musculoskeletal inactivity
6. Latex Allergy Response: A response to natural latex rubber products
These six subcategories of nursing diagnoses provide the nurse with the
opportunity to relate specific nursing interventions to the diagnosed problem.
For example, the specific nursing diagnosis for the situation of a toddler in
the home environment encountering medications on a nightstand would be Risk for Poisoningrelated to medicines not stored in
locked cabinets and accessible to children. The level of risk would be
increased if the medications on the client’s nightstand were in open containers
or the closed containers failed to have childproof caps. The subcategory
diagnosis provides specific nursing interventions directed at the level of risk
for the toddler and the need for client teaching.
Self-Care Deficits
A self-care deficit exists when the client is not able
to perform one or more of the activities of daily living.
Other
Nursing Diagnoses
Clients who are at risk for injury and infection or have a self-care
deficit may have other problems. These associated physiological and
psychological problems are discussed in detail in other chapters in this unit.
The common nursing diagnoses that often accompany diagnostic labels for risk or
self-care deficits are:
• Imbalanced
Nutrition (specify less
than body requirements or more than body requirements)
• Ineffective
Protection
• Impaired
Tissue Integrity
• Impaired
Oral Mucous Membrane
• Impaired
Skin Integrity
• Social
Isolation
• Risk
for Loneliness
• Ineffective
Coping
• Impaired
Physical Mobility
• Hopelessness
• Powerlessness
• Deficient
Knowledge (specify)
• Acute
Pain
• Anxiety
• Fear
This list is not all-inclusive but gives an indication of the number of
related problems that need to be considered when
planning care.
OUTCOME
IDENTIFICATION AND PLANNING
The primary nursing goal is to provide safe care through the
identification of actual or potential hazards and the implementation of safety
measures. The assessment data are reviewed with the client, and the nurse
records the areas in which the client indicates a need for change and health
teaching, for example, age-related exercise or maintaining a safe environment.
These findings are incorporated into the plan of care, reflecting the individualized
needs of each client.
During the planning phase, the nurse collaborates with the client and
other health care providers to determine the goals, outcomes, and interventions
and manipulates the external environment to reduce the risk of injury and infection.
Identified outcomes provide direction for the nursing care that is implemented
to reduce the risk of injury and infection.
Another critical element of the care plan is client/caregiver education
related to the identification of potential hazards and health promotion
practices.
The nursing care plan should include safety measures that educate
clients about preventive actions and modification of an unsafe environment, for
example, proper use of a call light or the side effects of medications.
Table 31-3 discusses the basic components of care planning and outcome
measurements for clients at risk or with a self-care deficit. Sample statements
of goals and expected outcomes are included in Table 31-3. The nursing
interventions are statements taken from the Nursing Intervention Classification
System. For each of these nursing interventions, there are specific actions
taken by the nurse to individualize the care for each client. The nurse could
use Gordon’s Functional Health Patterns to plan care. Gordon’s Functional
Health Patterns that may be used for clients at risk or with a selfcare deficit are health perception–health
management; activity-exercise pattern; and cognitive-perceptual pattern.
Nursing actions are discussed in detail in the following section.
IMPLEMENTATION
Nursing care implemented for clients with alterations in health
perception–health management or activity and exercise involves continual
assessment of client health risks and prioritization of risk reduction nursing
interventions, such as:
• Administration
of prescribed medications
• Provision
of balanced nutritional intake
• Promotion
of adequate rest and exercise
• Decreasing
the spread of infection
Implementation of safety measures may require an alteration in the
physical environment as directed by the fall prevention protocol or Standard
Precautions.
Nursing measures to counter common physical hazards that impair
environmental safety are maintaining electric beds in the low position with
side rails up and call light within easy reach and keeping the bedroom and
bathroom uncluttered to prevent falls. Some states consider side rails a form
of restraint. Nurses must be knowledgeable about statutory provisions relative
to health care in their state.
Raise
Safety Awareness and Knowledge
Nurses in all settings must demonstrate an awareness of safety hazards
and teach clients accordingly. Clients must be aware of and knowledgeable about
safety precautions in order to prevent injuries. Clients may also need specific
safety information on oxygen, intravenous equipment, use of heating devices,
and automatic bed controls.
A Food and Drug Administration (FDA) safety alert addressed entrapment hazards with side rails on hospital beds. The FDA received 102 reports of head and body entrapment incidents that resulted in 68 deaths, 22 injuries, and 12 entrapments without injury that occurred in hospitals, long-term care facilities, and private homes.
Prevent Falls
Falls occur among clients who are weak, fatigued, uncoordinated,
paralyzed, confused, or disoriented. The data obtained from the client’s fall
risk appraisal will identify which clients require special nursing measures to
prevent falls. The risk for falls can be reduced by:
• Good
supervision
• Orienting
clients to the environment and call system
• Providing
ambulatory aids (wheelchairs or walkers)
• Placing
personal belongings on tables near the bed
• Keeping
hospital beds in lowest position with side rails up
• Using nonslip mats and rugs
• Illuminating
the environment
Although falls do not necessarily constitute malpractice, they are a
major reason why nurses are involved in lawsuits (Ignatavicius,
2000). Sullivan and Badros(1999)
and Ignatavicius (2000) identify the need for
registered nurses to assess patients’ risk of falls and implement evidence-based
interventions. The concept ofevidencebased practice (EBP) refers to health care
based on research findings, expert consensus, or both (Davis & Madigan,
1999).
Apply
Restraints
Restraints are protective devices used to limit the physical activity of a client
or to immobilize a client or extremity. Restraints are used to protect the
client, allow for treatment in a safe environment, and reduce the risk of
injury to others.
The use of restraints has become very controversial because of client
injuries from restraints. The Omnibus Budget Reconciliation Act (OBRA) of 1987
and the Health Care Financing Administration regulations of 1999 governing
client’s rights are forcing a reexamination of how clients are cared for in
acute and critical care settings (Bower & McCullough, 2000). In response to
more individualized care regarding the use of restraints, the Joint Commission
on Accreditation of Healthcare Organizations (JCAHO) revised their standards
for restraint use with nonpsychiatric clients;
see the accompanying display for JCAHO-revised standards.
Nurses must document, according to the institutional protocol, the
application and care of the client in restraints (see the accompanying
display).
Restraints used to either limit physical activity or immobilize a client
can be physical or chemical.
Physical restraints reduce the client’s movement through the application of a device. Most states require a physician’s order for the application of physical restraints. Chemical restraints are medications used to control the client’s behavior. Commonly used chemical restraints are anxiolytics and sedatives.
Ensure
Adequate Lighting
Adequate lighting assists in the visualization of environmental hazards.
Rooms should be adequately lighted so that the client can safely perform ADL
and health care providers can perform procedures. Lighting can be supplemented
by lamps and nightlights. Lighting can also assist in protecting the home
against crime.
Remove
Obstacles
Obstacles in heavily traveled areas of health care facilities or homes
are a risk to the client’s safety. Older adults or persons who are unfamiliar
with the environment are at greatest risk of injury from obstacles. The risk
that obstacles pose can be reduced by keeping hallways clear, removing excess
furniture from heavily traveled areas, removing all electrical cords or taping
cords securely to the floor, removing throw rugs, applying nonslip pads to rugs, cleaning up spills
immediately, and removing objects that could fall from the tops of appliances.
Reduce Bathroom Hazards
Bathrooms pose a threat to the client in the home because of the
presence of water and storage of medication.
Common bathroom accidents are falls, scalds or burns, and poisonings.
Bathroom accidents can be reduced by the use of grab bars near the tub, shower,
and toilet; nonslip mats in the tub and shower; and a
secured bathroom rug near the tub or shower. Other safety measures include
checking the temperature of the water before entering tub or shower; checking
the thermostat setting on the water heater; and storing medications in a locked
cabinet, out of reach of children or disoriented or confused adults.
Prevent
Fire
Fire is a potential danger to all people in an institutional or home
environment. Immobilized or incapacitated clients are at increased risk during
a fire. Common causes of fire are smoking in bed, discarding cigarette butts in
trash cans, and faulty electrical equipment. Fire occurs with the interaction
of three elements: sufficient heat to ignite the fire, combustible material,
and oxygen to support the fire.
Nursing goals are fire prevention and protection of clients during a
fire. Nursing interventions aimed at preventing or reducing the risk of fire include:
• Clearly
marking fire exits
• Knowing
locations of fire extinguishers and their operation
• Practicing
fire evacuation procedures
• Posting
emergency phone numbers by all telephones
• Keeping
open spaces and hallways clear of clutter
• Checking
electrical cords and outlets for exposed or damaged wires
• Reporting
identified electrical hazards
• Educating
clients about fire hazards
In the event of a fire, follow institutional policy and procedures for
fire containment and evacuation.
Nursing interventions during a fire are directed at protecting the client from injury
and containing the fire. Nurses should be familiar with the location of
fire alarm pull boxes. If a fire occurs, the nurse should utilize the nearest
fire box for notification and move clients to safety.
Nurses should be familiar with the use of fire extinguishers and their
locations. The fire extinguisher should be directed toward the base of the
fire. The four types of fire extinguishers used are water, carbon dioxide,
regular dry chemical, and multipurpose dry chemical. Each
type of fire extinguisher is used for a specific class of fire, as discussed in
Table 31-5.
Ensure
Safe Operation of Electrical Equipment
Clients have contact with a variety of electrical equipment in the
hospital environment, such as bed controls and intravenous and patient-controlled
analgesia (PCA) pumps. All electrical equipment should have a threepronged electrical plug that is grounded. A
grounded plug transmits any stray electrical current from equipment to the
ground. To protect the client from electrical injury, the nurse should read the
warning labels on all equipment, use only grounded electrical equipment, check
for frayed electrical cords, avoid overloading circuits, and report any shocks
received from equipment to the biomedical department (see Figure 31-9).If a client
receives an electrical shock, the nurse should turn off or remove the electric
source before touching the client. Then, the client’s pulse should bechecked. If the client has no pulse, CPR should be
initiated.
If the client has a pulse, the nurse should assess vital signs, mental
status, and skin integrity for burns. A physician should be notified of the
event. The nurse should note points of entry and exit of electrical current to
assess for potential complications.
Reduce Exposure to Radiation
Clients are exposed to radiation during diagnostic testing and
therapeutic interventions. Injury can occur from radiation if there is
overexposure or exposure to untargeted tissues. Exposure to untargeted tissues
can occur with radiation implants that become dislodged.
General principles of radiation exposure and protection are based on
time, distance, and shielding. Protection from radiation therapy includes:
• Minimizing
time in contact with radiation source (implants or client)
• Maximizing
distance from radiation source (implants or client)
• Using
appropriate radiation shields
• Monitoring
radiation exposure with a film badge
• Labeling
all potentially radioactive material
• Never
touching dislodged implants or body fluids of client
Both the client and the nurse are at risk for radiation injury. The
client’s risk for injury can be reduced by educating the client about radiation
treatment and necessary precautions, placing the client in a private room, and
providing a lead apron when necessary to protect nontargeted body tissues. The nurse’s risk for
injury can be reduced by observing all radioactive labels, wearing gloves when
handling radioactive body discharges, washing hands, wearing lead aprons,
disposing of radioactive substances in special containers, reducing time of
client contact, and wearing badges that measure the amount of radiation
exposure.
Prevent
Poisoning
A poison is any substance that causes an
alteration in the client’s health, such as injury or death, when inhaled,
injected, ingested, or absorbed by the body. Antidotes and treatments are
available for some but not all types of poisonings. Direct and indirect causes
of poisonings are:
• Inadequate
supervision of children
• Ingestion
of household plants
• Improper
storage of toxic substances
• Insect
or snake bites
• Accidental
ingestion of a toxic substance or medication overdose
The poison control center should be notified when poisoning is
suspected. The person reporting the poisoning should be prepared to state the
amount and type of poison ingested, inhaled, or injected, client’s age, and
symptoms. Clients who have ingested poison should be turned on their side to
prevent aspiration while awaiting further treatment. Client education about
safety measures can prevent some accidental poisonings.
The following Client Teaching Checklist provides some safety measures to prevent accidental poisoning. Keep syrup of ipecac available at all times.
Reduce
Noise Pollution
Noise pollution, a situation that results when the noise level becomes
uncomfortable for the client or staff, frequently occurs in the health care
setting as a result of visitor traffic, medical equipment, and personnel. It
can result in an unorganized environment, hearing loss, and sensory overload. Sensory
overload is an increased perception of the intensity of auditory and visual
stimuli.
Sensory overload can alter a client’s recovery by increasing anxiety,
paranoia, hallucinations, and depression.
Safety measures include maintaining a quiet environment, traffic
control, and providing earplugs.
Provide for Client Bathing Needs
Bathing of clients is an essential component of nursing care. Whether
the nurse performs the bath or delegates the activity to another health care
provider, the nurse retains the responsibility for assuring that the hygienic
needs of the client are met. The type of bath provided will depend on the
purpose of the bath and the client’s self-care ability. The two general
categories of baths are cleaning and therapeutic.
Cleaning
Baths
Cleaning baths are provided as routine client care. The purpose of a
cleaning bath is personal hygiene. The five types of cleaning baths are shower,
tub, self-help, or assisted bed bath, complete bed bath, and partial bath.
Shower
Most ambulatory clients are capable of taking a shower. Clients with limited physical ability can be accommodated by placing a waterproof chair in the shower (Figure 31-28). The nurse provides minimal assistance with a shower. The Nursing Checklist discusses guidelines for helping clients with tub or shower baths.
Tub
Clients frequently prefer and enjoy tub baths. A tub bath permits washing and rinsing in the tub. Tub baths can also be therapeutic. Clients with limited physical ability should be assisted with entering and exiting the tub.
Self-Help
A self-help, or assisted, bed bath is used to provide hygienic care for
clients who are confined to bed. In the self-help (assisted) bed bath, the
nurse prepares bath equipment but provides minimal assistance. This assistance
is usually limited to washing difficult-to-reach body areas such as the feet
and back.
Complete
Bed
A complete bed bath is provided to dependent clients confined to bed.
The nurse washes the client’s entire body during a complete bed bath. Procedure
31-9 outlines the actions involved in giving a complete bed bath.
Partial
A partial (or abbreviated) bath consists of cleaning only body areas
that would cause discomfort or odor if not washed thoroughly. These areas are
the face,axillae, hands, and perineal area. The nurse or client may perform
a partial bath depending on the client’s self-care ability. Partial baths may
be performed with the client lying in bed or standing at the sink.
Therapeutic
Therapeutic baths require a physician’s order stating the type of bath,
temperature of water, body surface to be treated, and the type of medicated
solutions to use. A therapeutic bath is usually performed in a tub and lasts
about 20 to 31 minutes. Therapeutic baths are classified as hot or warm water,
cool or tepid water, soak,sitz,
oatmeal or Aveeno,
cornstarch, or sodium bicarbonate, depending on the prescribed type of bath.
Hot- or warm-water tub baths are used to reduce muscle spasms, soreness,
and tension. Hot- or warm-water baths, however, have the potential for causing
skin burns. Cool or tepid baths are used to relieve tension or lower body
temperature. The nurse needs to prevent chilling and rapid temperature
fluctuations during a cool or tepid bath.
A soak can include the entire body or be limited to only one body part.
A soak consists of applying water, with or without a medicated solution, to
reduce pain, swelling, or irritation or to soften or remove dead tissue.
Sitz baths cleanse and reduce inflammation in the perineal and anal areas. Sitz baths are commonly used for hemorrhoids
or anal fissures and after perineal or
rectal surgery. Skin irritations can be soothed with oatmeal or Aveeno,
cornstarch, or sodium bicarbonate baths.
Provide
Clean Bed Linen
After a bath, clean linens are placed on the bed to promote comfort. If the
client is able to get out of the bed, assist the client to a chair and proceed
with making the bed. Procedure 31-10 describes the steps involved with making
an unoccupied bed. After surgery, the client should be returned to a clean bed
with the linens folded to the foot of the bed to promote easy client transfer.
If the client is unable to get out of the bed, refer to Procedure 31-11 for a description of the steps involved in making an occupied bed. Assistance will be needed if the client is in traction or cannot be turned. Care must be taken to avoid disturbing the traction weights. If the client cannot be turned, change the linen from head to toe. Place a waterproof draw sheet on the beds of clients who are incontinent or have profuse drainage.
Provide
Skin Care
The skin functions as a protective barrier between the internal and
external environments. In addition, the skin functions to regulate body
temperature, secrete sebum, excrete sweat, transmit sensations, and facilitate
absorption of vitamin D.
Skin care provides cleansing and conditioning to promote the optimal
functioning of the skin. It consists of providing adequate nutrition, baths, perineal care, and back rubs. Excessive or
abrasive skin care can damage skin and result in loss of function. Performing
skin care provides an excellent opportunity for the nurse to assess skin
integrity.
Perineal Care
Perineal care is cleansing of the external genitalia, perineum, and surrounding area. Perineal care is also referred to as “peri-care” or “perineal-genital”
care. The purposes of perineal care
are to prevent or eliminate infection and odor, promote healing, remove
secretions, and provide comfort. Perineal care
can be provided alone or as part of the bed bath.
Perineal care may be an embarrassing procedure for both the client and the nurse,
especially if the client is of the opposite sex. Clients who are embarrassed
may elect to perform their own perineal care.
In this situation, the nurse should provide the client with warm water, moistened washcloth, soap, a dry towel, and privacy. If the client is unable to performperineal care, the nurse is responsible for providing this care in a professional and private manner.
Offer
Back Rubs
Back rubs and massages stimulate the client’s circulation, relax muscles,
and relieve muscle tension as well as provide the nurse with an opportunity for
skin assessment.
Emollient creams and lotions are used to facilitate the rubbing and
lubrication of the skin during a back rub or massage.
The client is positioned prone or side-lying. Nurses create friction and
pressure by rubbing their hands on the client’s skin. The friction creates
heat, which dilates the peripheral circulation and increases the blood supply
to the skin. The pressure provides manual stimulation to muscle fibers, which
relaxes the muscles.
Prior
to performing a back rub or massage, the nurse must assess for
contraindications. Caution should be exercised when massaging limbs. Massaging
limbs, especially the lower limbs, could dislodge a thrombus (blood clot),
creating an embolus (circulating blood clot). Bony prominences should be massaged lightly to avoid
damaging underlying tissue.
Provide
Foot and Nail Care
Proper foot and nail care are essential for ambulation and standing.
Foot and nail care are often ignored until problems exist. Common problems with
feet and nails may be a direct result of abuse and neglect, such as from
inadequate foot and nail hygiene, fingernail and cuticle biting, incorrect nail
trimming, poorly fitted shoes, and exposure to harsh chemicals. These problems
result in alterations of skin integrity with the potential for infection.
The first signs of foot and nail problems are usually pain or
tenderness. These symptoms affect a client’s posture and may result in limping
with subsequent strain on certain muscle groups. Clients with illnesses such as
diabetes mellitus need special foot and nail care. Clients with diabetes
mellitus experience alterations in circulation that predispose them to foot
problems.
The purposes of foot and nail care are to prevent infection and soft
tissue trauma from ingrown or jagged nails and to eliminate odor. Hygienic care
of feet and nails consists of regular trimming of nails; cleaning under nails;
cleaning, rinsing, and drying feet and nails; and wearing properly fitted
shoes. The following Nursing Checklist discusses the specific interventions
that should be taken in providing foot and nail care.
Soaking of nails assists with their cleaning if nails are dirty or
thickened. An orangewood stick is used to clean under nails since a metal
instrument can roughen the nail and cause it to harbor dirt. The safest
instrument to trim nails is the nail clipper; however, some clients feel that
cutting the nails makes them brittle. If the client chooses not to cut the nails,
the nails should be filed straight across. Special attention should be given to
drying the areas between the toes.
An emollient, such as cold cream, helps to keep nails and cuticles soft.
Callused areas should never be cut. Repeated soaking usually facilitates
the removal of calluses. Lotion should be applied to the foot to maintain
moisture and soften callused areas. If the client’s feet maintain excessive
moisture (sweat), water-absorbent powder should be applied between the toes.
The client should wear clean, properly fitted shoes.
The fit should not be extremely tight but should be snug enough to provide support to the foot. An arch support should be in each shoe. Shoe size should be large enough so that the shoe is one-half inch longer than the longest toe. Common foot problems can often be alleviated by assessing footwear and providing proper education on footwear and foot and nail care.
Provide
Oral Care
The oral cavity functions in mastication, secretion of mucus to moisten
and lubricate the digestive system, secretion of digestive enzymes, and
absorption of essential nutrients. Common problems occurring in the oral cavity are:
• Bad
breath (halitosis)
• Dental
caries (cavities)
• Plaque
• Periodontal
disease (pyorrhea)
• Inflammation
of the gums (gingivitis)
• Inflammation
of the oral mucosa (stomatitis)
Poor oral hygiene and loss of teeth may affect a client’s social interaction and body image as well as nutritional intake. Daily oral care is essential to maintain the integrity of the mucous membranes, teeth, gums, and lips. Through preventive measures, the oral cavity and teeth can be preserved. Preventive oral care consists of fluoride rinsing, flossing, and brushing.
Fluoride
Researchers have determined that fluoride can prevent dental caries. This
finding has led to the fluoridation of water supplies in many communities.
Fluoride is a common component of mouthwashes and toothpastes.
However, persons with excessive dryness or irritated mucous membranes
should avoid commercial mouthwashes because of the alcohol content, which
causes drying of mucous membranes.
Fluoride supplements are available without a prescription.
Infants can be given fluoride drops as early as 2 weeks of age to
prevent dental caries. Nurses should educate clients about fluoride being an
excellent preventive measure against dental caries.
However, excessive fluoride usage can affect the color of tooth enamel.
To prevent discoloration of the tooth enamel, fluoride should be administered
with a dropper directed toward the back of the throat.
Flossing
Flossing should be performed daily in conjunction with brushing of
teeth. Flossing prevents the formation of plaque, removes plaque between the
teeth, and removes food debris. Dental caries and periodontal disease can be
prevented by regular flossing. Flossing is best performed after toothpaste is
applied to the teeth but before brushing . This order
permits the fluoride in the toothpaste to have direct contact with the tooth
surfaces, thus preventing dental caries.
Flossing can also be performed after brushing, but brushing first does
not maximize the fluoride’s contact with the tooth surfaces.
Brushing
Brushing of teeth should follow flossing. Teeth should be brushed after
each meal. Brushing should be performed using a dentifrice (toothpaste) that
contains fluoride to aid in preventing dental caries. An effective homemade
dentifrice is the combination of two parts salt with one part baking soda.
Brushing removes plaque and food debris and promotes blood circulation of the
gums.
Dentures should be brushed using the same brushing motion as that used
for brushing teeth.
Oral
Care for the Unconscious Client
Oral care for the unconscious client maintains a clean oral cavity and
intact mucous membranes. Special care should be exercised when performing oral
care to unconscious clients to prevent client aspiration or injury to the nurse
(client biting because of gag reflex). The accompanying Nursing Checklist
provides essential safety guidelines for providing oral care to unconscious
clients.
Provide
Hair Care
Hair affects a client’s personal appearance and body image. Hair functions to
maintain the body temperature and as a receptor for the sense of touch.
Assessment of hair texture, growth, and distribution provides
information on a client’s general health status.
Common hair problems are dandruff, hair loss, tangled or matted hair,
and infestations such as pediculosis and
lice. Hair problems can be reduced by daily hair care, which helps to promote
hair growth, prevent hair loss, prevent infections or infestations, promote
circulation of the scalp, evenly distribute oils along hair shafts, and
maintain the client’s physical appearance. Hair care consists of brushing and
combing, shampooing, shaving, and mustache and beard care.
Brushing and Combing
Hair should be brushed or combed daily according to the client’s
preferred hairstyle. Brushing and combing stimulate circulation to the scalp,
distribute oils along hair shafts, and arrange the placement of hair. A clean
brush or comb should be used. Hair should be brushed from the scalp toward the
hair ends. Sensitive scalps should be brushed or combed gently. Wetting the
hair with water before brushing or combing can prevent damage to the hair and
painful pulling of the scalp.
Clients who are immobilized may have tangled or matted hair. Care should
be taken to prevent pain when combing tangled or matted hair by holding the
tangled hair near the scalp while combing. If the client permits, the hair can
be braided to avoid tangling or matting, but braiding the hair tightly should
be avoided since tight braids may cause pain and hair loss. A nurse must
receive written informed consent to cut a client’s hair.
Shampooing
When soiled, hair should be shampooed according to the client’s usual
routine. The purposes of shampooing are to stimulate scalp circulation, remove
soil from hair, and facilitate brushing and combing. Hair can be shampooed in
the tub, in the shower, at the sink, or in the bed depending on the client’s
abilities and preferences.
Clients confined to bed can have their hair shampooed with water or with shampoos that do not require water (see Nursing Checklist: Shampooing Hair in Bed). Hair is shampooed by thoroughly wetting all hair, applying about a teaspoon of shampoo, lathering shampoo, and gently massaging the scalp with the pads of the fingertips. Hair should be rinsed thoroughly after shampooing. Hair should be dried with an absorbent towel, then brushed or combed in the preferred hairstyle.
Shaving
Shaving is the removal of hair from the skin surface.
Males often shave to remove facial hair, and women may shave to remove
leg and/or axillary hair. Operative procedures may also
require skin preparation that requires shaving of an area of the body.
Shaving may be performed before, during, or after the bath. Care should
be used to avoid cutting the skin. Prior
to shaving, the area should be washed with soap and warm water to soften the
hair. A warm washcloth may be placed over the area for a few minutes to assist
with softening the hair. A shaving cream or mild soap is applied to the area to
ease hair removal. To shave, the skin should be pulled taut. The razor is held
at a 45 degree angle
and moved over the skin in short, firm strokes in the direction of hair growth.
After the skin is shaved, it should be washed, rinsed, and patted dry.
Mustache
and Beard Care
Mustaches and beards require daily care. Mustache and beard care
consists of keeping the hair clean, trimmed, and combed. Mustaches and beards
can be washed with soap or a shampoo. Frequently, mustaches and beards require
only gentle wiping with a moist washcloth. A mustache or beard should never be
shaved by the nurse without written informed consent.
Provide
Eye, Ear, and Nose Care
Eye, ear, and nose care should be included in routine hygienic care.
Eyes
Eyes are continually cleansed by the production of tears and movement of
eyelids over the eyes. Eyelids should be washed daily with a warm washcloth
from the inner to outer canthus. Eyelashes function to prevent foreign material
from entering the eyes and conjunctival sacs.
Eyelashes and eyebrows should be washed as necessary.
A client’s artificial eye (prosthetic) may require daily cleaning, which
requires that the eye be removed from the eye socket and washed (see Procedure
31-14). Some artificial eyes are permanently implanted.
Comatose clients have special eye care needs since they lack a blink
reflex. These clients require frequent instillations of lubricants or eyedrops to prevent corneal abrasions. The
accompanying Nursing Checklist describes eye care for the comatose client.
Contact
Lenses
The nursing history should indicate if the client wears contact lenses,
and the routine care and level of assistance should be recorded on the client’s
care plan.
Clients who can insert, remove, and manage the care of their lenses will
require minimal assistance from the nurse. If the client is unable to assist
with lens care and also has corrective eyeglasses, suggest to the client that
he or she wear the eyeglasses during hospitalization.
There are two types of contact lenses: hard and soft. Each type requires
different cleaning and care (see
Procedure 31-14). During emergency situations, the nurse should remove the
lenses and place them in the appropriate solution.
Ears
Hearing can be affected by foreign material or wax in the external ear
canal. Cleaning of the ears involves cleaning of the external ear canal and
auricles. Objects should not be inserted into the ear canal. Excess wax or
foreign material should be removed by gently washing the external ear and
auricles with a warm washcloth while pulling the ear downward in the adult
client. Irrigation of the ear may be necessary to remove dried wax. The
physician should be notified prior to irrigation of the ear.
Hearing
Aids
Hearing aids amplify sound. The health history should indicate if the
client is wearing a hearing aid and the plan of care should discuss the
cleaning schedule of this aid. Clients with hearing aids should clean the ear
mold regularly to ensure proper functioning. There are four types of hearing aids:
• Body-worn
• Eyeglass
• Behind
the ear
• In
the ear
Some hearing aids have a telephone switch that can be turned on and off.
If the hearing aid is not functioning properly, check the on-off switch
and volume control, battery (replace as necessary), plastic tubing for cracks
and loose connections, and telephone switch, which should be in the off
position unless the client is using the phone. Hearing aids should be handled
carefully since dropping or bumping the hearing aid can damage its delicate
mechanisms. When not in use, the hearing aid should be stored in a container
because dust and dirt can damage the mechanism.
When communicating with a client who has a hearing aid, you should
address the client by name and then wait for the client to face you before
speaking further. Always face the client and speak in a slow, natural voice.
Shouting causes distortion of sound and usually makes the client feel
uncomfortable.
Nose
The nose provides the sense of smell, prevents entrance of foreign
material into the respiratory tract, humidifies inhaled air, and facilitates
breathing. Excessive or dried secretions may impair nasal function. Excessive
nasal secretions are removed by inserting a cotton-tipped applicator moistened
with water or saline into the nostrils.
The applicator should not be inserted beyond the cotton tip. Infants may
have excessive nasal secretions removed by a suction bulb. Clients with a nasogastrictube
should receive meticulous skin care to the nose area to prevent skin breakdown.
EVALUATION
Evaluation is based on the achievement of goals and client expected
outcomes, regardless of the setting.
Clients with alterations in health perception–health management pattern
or activity-exercise pattern are at risk for injury, infection, and self-care
deficits. Keeping the client free from injury and infection requires frequent
reassessment, through the use of risk appraisals, with timely adjustments made
in the plan of care in order for nursing interventions to be effective.
It is imperative that the client not only be free of injury during
hospitalization but also develop a true awareness of the internal and external
factors that increase the risk for injury. Achievement of this outcome measure
is directly related to the behaviors the client observes while in the hospital
and through client teaching. Modification of a home to a safe environment is
evidence for the home health nurse that learning has taken place.
Adherence to barrier precautions is critical in preventing the spread of
infectious agents, especially nosocomial infections
to clients, self, and other health care workers. The nurse needs to correlate
the client’s diagnostic laboratory results and temperature in evaluating the
expected outcome of remaining free of signs and symptoms of infection. If the
nurse is caring for a client with an infection, the evalaution should indicate the stage of the
inflammatory process (refer to Table 31-1).
The therapeutic value of hygiene is maximized when the client can particiapte and is kept free from infection and
alterations in skin integrity. Evaluation should identify the client’s level of
functioning in self-care activities.
At the time of discharge from the hospital, appropriate referrals should
be made to home health care agencies to assist the client in achieving optimum
functioning levels for safety and hygienic practices. Clients at risk for
infection should have follow-up visits by the home health nurse to measure the
effectiveness of client teaching and resources in the home to prevent the
transmission of infections.
KEY CONCEPTS
• Factors influencing client safety are age, lifestyle, sensory and
perceptual alterations, mobility, and emotional state.
• Types of accidents that can occur in the health care setting are client behavior,
therapeutic procedure, and equipment accidents.
• Assessment of a safe environment consists of performing an injury risk
appraisal.
• Nurses can help clients in maintaining a safe environment by resolving
or alleviating hazards related to falls, lighting, obstacles, bathroom hazards,
fire, electricity, radiation, poisoning, and noise pollution.
• The chain of infection involves a biological agent, a reservoir of the
agent, a portal of exit, a mode of transmission, a portal of entry of the agent
into the host, and a susceptible host.
• Medical and surgical asepsis prevent the transfer of microorganisms by
implementation of practices that reduce the number, growth, or spread of
microorganisms from an object or area.
• The new guidelines from the CDC require that transmission-based
precautions be used for specific syndromes that are highly suspicious for
infections until a diagnosis is confirmed.
• Hygienic practices are influenced by body image, social and cultural
practices, personal preference, socioeconomic status, and knowledge.
• Basic hygienic practices include bathing, skin care, perineal care, back rubs, foot and nail care,
oral care, hair care, and eye, ear, and nose care.